Smoke Inhalation

Key Features

• Among patients treated for burn injuries, 33% also have pulmonary injury from smoke inhalation

• Inhalation injury occurs as a result of

  • Impaired tissue oxygenation

  • Thermal injury to the upper airway

  • Injury to the lower airways and lung parenchyma

Clinical Findings

• Bronchorrhea and bronchospasm are seen early after exposure along with dyspnea, tachypnea, and tachycardia

• Labored breathing and cyanosis may follow

• Diffuse wheezing and rhonchi

• Acute respiratory distress syndrome (ARDS) may develop 1–2 days after exposure

• Sloughing of the airway mucosa may occur in 2–3 days, leading to airway obstruction, atelectasis, and worsening hypoxemia

• Bacterial colonization and pneumonia are common 5–7 days after exposure

• Complications become evident by 18–24 hours and include

  • Mucosal edema, upper airway obstruction, and impaired ability to clear secretions, all of which produce inspiratory stridor

  • Respiratory failure in severe cases

Diagnosis

• Arterial blood gases (ABGs) are necessary to evaluate oxygenation and rule out carbon monoxide poisoning

• Examination of the upper airway with a laryngoscope or bronchoscope is superior to physical examination

Treatment

• Early management includes

  • Use of a high-humidity face mask with supplemental oxygen

  • Gentle suctioning to evacuate oral secretions

  • Elevation of the head to 30 degrees

  • Topical epinephrine

• Endotracheal intubation often necessary to establish airway patency and likely needed with deep facial burns or oropharyngeal or laryngeal edema; tracheotomy should be avoided

• Ongoing treatment includes

  • Supplemental oxygen

  • Bronchodilators

  • Suctioning of mucosal debris and mucopurulent secretions via an indwelling endotracheal tube

  • Chest physical therapy

  • Adequate humidification of inspired gases

• Positive end-expiratory pressure has been advocated when there is pulmonary edema

• Fluid management and close monitoring for secondary bacterial infection, but prophylactic antibiotics are not recommended

• Helium-oxygen (Heliox) helpful if labored breathing

• Corticosteroids may be harmful

• Close monitoring with ABGs and oximetry

• Patients who survive should be watched for the late development of bronchiolitis obliterans